Category Archives: Maternal Mental Health

Associate Professor Simone Honikman, University of Cape Town’s (UCT), says more needs to be done for the treatment and prevention of postnatal depression.

Dr Honikman, who is also the Director of the Perinatal Mental Health Project (PMHP), says mothers who do not have a support system and those who live in poverty are more likely to suffer from postnatal depression.

In South Africa, studies have found that more than 30% of women living in adversity will experience a mental illness during or after pregnancy.

Life changes around pregnancy can make women more vulnerable to mental illness, therefor women are at higher risk of developing depression or anxiety during the perinatal period.

Perinatal period refers to the time from conception until the end of the first year after birth.

Dr Honikman highlights “that it is important to realise that depression is very common, not only during pregnancy but after in that first year […] People do get better from this illness, like from any other illness”. Furthermore, it is imperative to start “treatment early, so that we can prevent it from getting worse or prevent it in the first place.”

Perinatal mental health has been a particular interest for me and my research journey into this field began during my Master’s degree. Following a natural trajectory, I began my current (PhD) research in perinatal depression when this opportunity was presented in the PRIME South Africa project, particularly as one of the focal areas of interest in PRIME was to develop mental health programmes to reduce the mental health treatment gap in maternal mental health care, and my principal role as the PRIME project coordinator for South Africa provided a unique opportunity to engage with and understand the health context before commencing my study.

Perinatal primary health care in South Africa has focussed strongly on maternal and child morbidity and mortality, and perinatal mental health in this context has been mostly ignored. Perinatal depression is associated with many health and social burdens including negative child outcomes such as stunting, poor cognition and socio-emotional development, and adverse mental health outcomes for mothers, yet despite high prevalence rates perinatal depression has historically been neglected in public health care in South Africa.

A situational analysis of maternal mental health services in the PRIME South Africa site i.e. Dr Kenneth Kaunda District (DKKD) in the North West Province, revealed an absence of routine and/or dedicated perinatal mental health services at primary health care level. Despite the National Mental Health Policy Framework and Strategic Plan 2013–2020 having mooted plans to address perinatal mental health at primary health care level there has been little progress towards including mental health in the maternal and child health platform and/or Basic Antenatal Care (BANC) package that is used in routine perinatal care.

Food insecurity is an ongoing concern in Africa. According to the State ofFood Security and Nutrition in the World report by FAO (Food and Agriculture Organization, 2018), the number of undernourished people has increased to nearly 821 million worldwide. Africa remains the continent with the highest prevalence of undernourishment, affecting over 250 million people.

Recent studies show that women with children make up a significant component of the households affected by food insecurity. In our Q&A we highlight this important topic and its connection to maternal mental health.

Food security is defined as having enough safe and nutritious food to sustain a healthy life. In contrast, food insecurity means that food is not sufficiently accessible or affordable, so households have difficulty securing adequate food.

What is maternal mental health?

Maternal Mental Health is a term that refers to the emotional state of women during and after pregnancy.

The relationship between food insecurity and poor maternal mental health is complex, with research showing that there are bi-directional associations between them. That means that suffering from food insecurity can have a negative impact on mental health and having mental health problems can negatively affect food security. The Perinatal Mental Health Project demonstrated these associations in a paper published in 2018.

How does food insecurity affect maternal mental health?

The negative physical health effects of poor maternal nutrition are well documented. Additionally, the emotional strain associated inadequate basic household resources, and how these resources are allocated substantially increases the overall household stress. Food insecurity can have persistent effects on the mental health of household members, especially those responsible for child care.

How can mental health problems during or after pregnancy affect food security?

In low-and-middle-income countries, maternal depression can is associated with an increased prevalence of food insecurity in the household by 50 to 80%. Mental health problems also impact the way food for the household is sourced. Mothers with depression or anxiety may find it more challenging to generate income, make contingency plans and draw on social networks for support. They are more likely to be in relationships characterised by abuse and control.

Even though the link between the two highlighted issues is being explored worldwide, there is little evidence for interventions that successfully break this cycle.

Currently, many interventions target one or the other issue. While food banks and support grants are aimed at improving the nutrition of mothers and consequently alleviates household food insecurity – they do not address the mental health implications of food insecurity on households. Similarly, maternal mental health services do not typically poverty relief or similar interventions, which could reduce the negative impact food insecurity has on households.

Combined interventions need to be developed and tested for their dual impact on both the mother’s mental health and the food security of the household.

Food Insecurity and the Risks of Depression and Anxiety in Mothers and Behavior Problems in their Preschool-Aged Children by Whitaker, R. C., Phillips, S. M., Orzol, S.M. (https://doi.org/1542/peds.2006-0239)

Food Insecurity/Food Insufficiency: An Empirical Examination of Alternative Measures of Food Problems in Impoverished U.S. Households by Scott, R. I.

“You are nothing” – that’s what Nosipho, a 19-year-old woman, was told by her mother on a regular basis. Nosipho’s stepfather was abusive and raped her over the course of four years. Eventually, she became pregnant and was diagnosed as HIV-positive. She told no-one about her story because she believed that no-one would care.

Sadly, many women in low-middle-income-settings have stories similar to that of Nosipho. The Perinatal Mental Health Project (PMHP) has a service site at the Hanover Park Midwife Obstetric Unit (MOU). When Nosipho attended the MOU for her first antenatal check-up she was also screened for depression, anxiety and suicidality. She was then referred to the PMHP counsellor, Liesl Hermanus.

Women living in disadvantaged communities, that are exposed to extreme hardship, multiple traumas and little social support, have a high chance of experiencing depression or anxiety around the time of pregnancy and childbirth. These mental health conditions can result in a higher chance of social exclusion, financial difficulties and vulnerability to experiencing violence. Women who are especially at high risk are those living with food insecurity, HIV/AIDS, intimate partner violence and insecure refugee status.

As a PMHP counsellor, Liesl provides support to women and girls who experience emotional distress during and after pregnancy. Since its inception in 2002, the PMHP is addressing the need for integrated mental health care for pregnant and postpartum women and girls in South Africa through research, advocacy and its clinical engagement with vulnerable women and their families.

Liesl can see the results of her efforts walking down the street, when former clients and their children approach her with gratitude, like this SMS one of the mothers sent “I finished my job application today. I want to say thanks for everything you did for me. You must continue to help other people, other people who are suffering, just like I was.”

About the PMHP

Based at the University of Cape Town, within the Alan J Flisher Centre for Public Mental Health, we provide mental health services for perinatal women (clinical services), train those who work with mothers in order to improve the quality of their care (training), form partnerships to promote the improvement of services and inform global interventions through robust research and advocacy.

How we operate

We envision mental health support for all mothers to promote their well-being and that of their children and communities. Our mission is to develop and advocate for accessible maternal mental health care that can be delivered effectively at scale, in low resource settings.

Our four programmes

We provide screening for pregnant women and girls for psychological disorders (depression and anxiety) at their first antenatal visit at our service site in Hanover Park. For those who are at risk, we offer free on-site psychosocial counselling, follow-up and case management for up to one year after birth.

In2018, the PMHP team screened 1860 clients, counselled 224 women and girls through 672 individual counselling sessions. At follow-up, 57% of the women who had received counselling stated that their problem was ‘much improved’ or ‘resolved’; 93% report successful bonding with their baby; 69% view their life as positive after counselling.

We provide training in the public health and social development sectors for all levels of staff in the community, social development and health care settings including the use of interactive methods, multi-media resources, distance-based learning opportunities and train-the-trainer courses. Our goal is to integrate maternal mental health into the routine practice of frontline providers in order to increase access to care for marginalised women. Our training aims also to shift negative attitudes, reduce stigma and eliminate client abuse.

We train between 700 and 1000 service providers annually in face-to-face seminars, workshops or courses. Our Training and Capacity Building programme works closely with our Research programme and partners with other academic and civil society organisations. Together we develop innovative, relevant and practical mental health training modules for use in urban and rural contexts.

We develop a range of open access multi-media resources to support our capacity building initiatives.

To determine the effectiveness and efficiency of all elements of the PMHP intervention package we conduct integrated, independent research. The research focusses on the distribution and determinants of several aspects of maternal mental health including depression, anxiety, suicidality, alcohol and substance abuse, food insecurity and domestic violence. We have recently developed and validated a brief mental health screening tool. We also partner with cutting-edge research initiatives that seek to address the knowledge gap for maternal mental health in resource-constrained settings. Our research work is coupled with uptake-strategies to ensure that the new knowledge produced is translated into policy and evidence-based practice.

We are currently involved in the evaluation, in distinct service contexts, of our Nyamekela4Care intervention which we have piloted and developed to embed in regular practice, care provider team knowledge generation, empathic skills practice, case sharing and self-care.

Our aim is to influence and change perceptions and awareness about maternal mental health. We translate the evidence-based research and experiences we gained in our clinical services and from others’ work in resource-constrained settings to engage with local and international change agents, including policy and programme makers and senior officials of governmental organisations.

Through several media platforms and public engagements, we focus on raising awareness among the general public, including mothers and families.

We actively support a range of government policy and implementation processes in health and social development.

We are a non-profit entity and need funding to do our work. Your donation will help us build a more positive future for women, their children and the communities in which they live. If you want to support us, follow this link to donate here

Although depression and anxiety can have devastating effects for any individual – women have an increased chance of being affected by these common mental disorders during the perinatal period, which can have long term consequences for both mother and child.

Domestic violence (DV) and intimate partner violence (IPV) are strongly linked to depression and anxiety in the perinatal period.

Zooming in on Domestic Violence as a risk factor

Domestic violence (DV) is defined as any physical, sexual, psychological or economic abuse that takes place between people who are sharing or have recently shared a home. Intimate partner violence (IPV) relates to violence committed by a current, ex- or would-be intimate relationship that causes physical, psychological or sexual harm to either partner.

The WHO has acknowledged that all forms of interpersonal violence leads to negative health outcomes and released a global plan of action to address interpersonal violence, particularly against women, girls and children. (More in this WHO report 2016)

In Africa, there is more violence against women than on any other continent. Compared to America, twice as many women In South Africa are killed by their partners.

Violence against women during pregnancy can have negative effects for both the mother and the child. Studies have shown that negative physical effects for mother and child can include fetal death by placental rupture, premature labour, low birth weight and haemorrhage after birth.

The negative psychological effects can include lowered self-esteem, depression, anxiety, substance or alcohol misuse. These effects, in turn, render women more vulnerable to experiencing domestic violence. Furthermore, abused women are more likely to delay getting pregnancy care and to attend fewer antenatal visits.

Research on IPV from four countries

Main findings from four countries show that there is a relationship between domestic and intimate partner violence.

A recent study from Australia found that out of the 4% of pregnant women who reported a history of IPV during a routine psychosocial assessment, more than 50% were immigrants. The highest number of women reporting abuse were born in Sudan and New Zealand, while women from China and India were least likely to report IPV. It is important to note that under-reporting is very likely in many communities and this may be due to a variety of reasons such as women’s experiences of shame, stigma and lack of appropriate responses or support from others.

Those women reporting IPV were more likely to report additional psychosocial concerns including depression, thoughts of self-harm and childhood abuse.

Another study conducted in Japan showed the association between verbal and physical abuse during pregnancy and linked it to postpartum depression. The study not only offers some insights into the significant influence of both verbal and physical abuse during pregnancy on postpartum depression, but also calls for regular screening for antenatal IPV by public health nurses who could identify those women who need further support, such as referral to centres for confidential advice and support.

Similar findings were reported from Malaysia, where the exposure to IPV was significantly associated with postnatal depression. The researchers of this study are also calling for training to healthcare professional to detect and manage both problems.

A recent South African study, conducted by the Perinatal Mental Health Project, showed 15% of nearly 400 pregnant women experienced IPV. We found a substantial proportion of women were additionally experiencing violence in the home at the hands of family members other than their partners, such as brothers, in-laws and grandparents. We found that abused pregnant women are more likely to be under 30 years of age, experience a range of mental health disorders, food insecurity and are more likely to be unemployed. They are more likely to have experienced abuse in the past and be unhappy with being pregnant.

Further research is needed to establish the best way to identify women at risk of domestic violence or intimate partner violence. A recent systematic review showed that there is promising evidence to indicate that mental health interventions for mothers may reduce their experiences of IPV. However, further research is required to determine the mechanisms and intensity of these interventions.

Training and supervision

Trauma-informed care, empathy training, referral-making skills and safety planning should be embedded as an integral part of the training and supervision systems for all frontline workers who engage with mothers, across different sectors.

Clinical and policy guidelines provided by the World Health Organisation are available here.

Systems strengthening

Political will, with the attendant resource allocation, is required to develop the structures able to protect and support survivors. These structures in health (physical and mental), justice, and the non-governmental sectors should operate in a co-ordinated and mutually enhancing way.

The World Health Organisation has produced an excellent manual for health managers for systems strengthening to respond to women subjected to IPV and sexual violence. This includes building awareness, advocating, analysing and planning as well as addressing leadership and governance factors.

The first 1000 days of a baby’s life (from conception to their second birthday) has been identified as a critical time in a child’s life. It has the potential to shape lifelong health and development. How does the mother’s wellbeing fit in with this? A healthy and emotionally well mother is better able to provide her child with the physical and emotional support and stimulation that they need for growth and development. Mothers need to be supported during this time.

There are many factors in a woman’s life that can put her at risk of experiencing mental distress during and after pregnancy. These include the lack of a supportive partner or family, an unintended pregnancy, poverty, food insecurity, HIV+ status and experience of domestic violence. Women who have experienced past trauma or who are refugees or migrants are also at higher risk.

About 1 in every 3 South African mothers suffers from common mental disorders – depression and anxiety – during pregnancy and in the first year after birth. This is approximately double the rates found in high-income countries.

In South Africa, there are many risk factors which may contribute to maternal mental disorders, especially among women living in poverty.

Maternal mental health has been getting more attention in the media, especially on social media. However, in South Africa and many other low-and-middle-income countries, mental illness is stigmatized and seen negatively. This means that many women do not want to admit to their feelings and will not seek help.

If left untreated, the risk of suicide is high in women experiencing maternal mental disorders. An article from the Economist highlights the case in Japan where suicide was the leading cause of death in pregnant and new mothers between 2015 and 2016. As a result, they have shifted their focus to be solely on the baby, to increased mental health care for mothers. “Japan is not alone in waking up to the inadequacy of care in early motherhood”

The Perinatal Mental Health Project was founded to address unmet mental health needs of pregnant women and new mothers in South Africa through research, advocacy and capacity building.

We believe maternal mental health needs to be routinely integrated into primary healthcare. The Mental Health Care Act (2002) and the National Mental Health Policy Framework and Strategic Plan (2013-2020) describe the need for mental health care to be integrated into general health services, in particular, services targeting vulnerable groups.

Pregnant women and new mothers are vulnerable and need mental health services that cater to their needs. This, in turn, will benefit their babies and children and the next generation.

Common mental health problems, such as depression and anxiety, that occur during pregnancy and in the year after childbirth are highly prevalent globally. In developing countries, the rates are much higher than in high-income settings. Women and girls who live in poverty and who experience violence are particularly vulnerable. In South Africa, about 1 in 3 women will experience depression or anxiety during or after their pregnancy.

Poor maternal mental health not only has adverse effects on mothers, but may negatively impact their children. Mental health problems in mothers is linked to maternal and infant mortality. Poor maternal mental health jeopardises the development of the foetus resulting in premature births and low birth weight infants. Social, behavioural and emotional development of children is also affected by the mental health of the mother. Many of these effects may be buffered by the presence of another supportive and well adult caregiver for the child. However, many mothers in resource-scarce settings are socially and emotionally isolated.

Many South Africa women‚ already in difficult situations‚ are experiencing violence during pregnancy at the hands of their intimate partners‚ a new study has found.

Of the 376 women who took part in the research‚ 15% had experienced intimate partner violence (IPV) during pregnancy‚ with forms of abuse ranging from sexual and physical to emotional and verbal.

This is against a backdrop of South Africa having intimate partner violence (among all women‚ not just those who are pregnant) which is “double that of the United States of America”‚ and which is as high as 71% in some communities.

The high level of violence during pregnancy in South Africa resulted from a combination of poverty-related factors.

Just published in the international BMC Women’s Health Journal‚ the study was carried out by a team from the University of Cape Town.

The sample was drawn from women attending antenatal services at a primary-level maternity facility in Cape Town.

The researchers found that the high level of violence during pregnancy resulted from a combination of poverty-related factors including food insecurity‚ mental ill-health‚ unemployment‚ unwanted pregnancies‚ and past experiences of abuse.

“In its most severe form‚ violence against pregnant women has been reported as a contributing cause of maternal deaths,” said researchers Sally Field‚ Michael Onah‚ Thandi van Heyningen and Simone Honikman.

It has also been associated with “inadequate uptake of antenatal care‚ with abused women being more likely to delay seeking pregnancy care and to attend fewer antenatal visits.”

For mothers and their unborn babies, results can include “low birth weight‚ foetal death by placental abruption‚ antepartum haemorrhage‚ foetal fracture‚ rupture of the uterus and premature labour”.

Also‚ they add that a “strong association” had been shown between thoughts of suicide and violence experienced by pregnant women.

They said that in South Africa‚ “high levels of violence occur within a context of multiple contributing social dynamics. These include prominent patriarchal norms where masculinity is associated with the defence of honour‚ harshness‚ and risk-taking.”

They added: “Poverty and gender inequalities contribute to the structural determinants of violence.

“Women in stable but unmarried relationships were more likely to have reported experiencing IPV than those who were married.”

Where to from here? The researchers said the study contributed towards a greater understanding of the risk profile for IPV among pregnant women in low-income settings.

This research and other PMHP findings are available open-source online!

In most societies, mothers are the primary providers of care to young children. This is a demanding task and the mental health of a mother is not only essential to her well-being, but that of her child’s physical health, nutrition and psychological well-being. However, most child development programmes do not adequately address maternal mental health.

Recent research has shown that about 20% of mothers in developing countries experience some form of mental health problems during or after childbirth. The United Nation’s Secretary-General António Guterres has recently acknowledged that the issue of mental health remains a largely neglected issue and announced the UN’s commitment to “working with partners to promote full mental health and well-being for all”.

Moreover, professionals in the field are pointing out that the mental health of mothers is critical to the success of the UN Sustainable Development Goals on health, nutrition and gender equality (SDG 3, 2 and 5).

In South Africa, the rate of pregnant and postnatal mothers suffering from common mental disorders (depression and/or anxiety) can reach up to one in three. Many of them are poor, come from disadvantaged communities and face many obstacles in accessing services and care.

Across Africa, the majority of women experiencing challenges to their mental health during the perinatal period (pregnancy and up to one year after the birth) are also exposed to gender-based violence, economic and gender inequalities, physical illnesses (including HIV), complications of childbirth and the stresses of childcare. Suicide has been identified as one of the leading causes of maternal death worldwide.

Unfortunately, health care systems in most African countries are not equipped to deal with the complex health and social challenges faced by most mothers. With competing physical health priorities and constrained resources, mental health care remains seriously neglected.

To challenge the status-quo and to improve the mental health of mothers in Africa, a group of individuals and organisations are working together in the newly established African Alliance for Maternal Mental Health (AAMMH).

AAMMH believes that a multi-sectoral approach is needed to tackle the causes of poor maternal mental health in Africa. The alliance calls for the integration of existing evidence-based interventions for the detection, prevention and treatment of maternal mental health problems into reproductive and child health programmes, supported by mental health services with specialist expertise.

This call for action is very close to the PMHP’s mission to develop and advocate for accessible maternal mental health care that can be delivered effectively in low-resource settings. We have thus become involved with the Global Alliance for Maternal Mental Health (GAMMH) over the past year since its formation and are now a proud founding partner of its first regional off-shoot, the AAMMH.

Together with colleagues in Malawi, we have been preparing for the upcoming launch on the 19 June in Lilongwe, Malawi. Prior to the launch, we will conduct a training workshop with health care providers and managers in maternal, mental and child health. On the launch day itself, we will be delivering a keynote address sharing the experience of the PMHP and will also be conducting a workshop towards establishing strategies for working partnerships across sectors for maternal mental health.

We hope our experience and work in South Africa, and in other low and middle-income countries, will contribute to the development and growth of this pan-African advocacy initiative. At the same time, we look forward to collaborating and learning from advocates, practitioners, trainers and researchers across Africa to strengthen the work we do in South Africa.

Diagnosis gap in Low- and Middle-Income Countries (LMICs)

Despite contributing significantly to maternal deaths and unproductive life years, common perinatal mental disorders (CPMD) often go undetected among women in low-resource regions. This can mean that up to 80% of women remain untreated in such settings. Resource-constrained primary care centers, high patient volumes, lack of recognition by health workers as well as increased task shifting to semi-skilled health workers contribute to this treatment gap. In order to encourage timely identification of CPMD among mothers followed by referrals, antenatal care provision centers are a promising platform in LMICs due to the high level of touchpoints between expectant women and health systems. In South Africa, for example, a mother’s contact rate with any antenatal care facilities is quite high at approximately 91%. […]

Lead author Thandi van Heyningen shares insight into progress and next steps for improving maternal mental health in low-resource settings:

“Where health system resources are scarce, one way of improving detection and improving access to treatment, is to integrate these services into existing, routine, primary health care services using a stepped care approach. Improving detection through routine antenatal screening may provide a vital first step, however there is a need to generate further evidence on the feasibility and acceptability of existing screening tools for use in such settings, and by non-specialist health care workers.”

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Food insecurity..

..the state of being without reliable access to a sufficient quantity of affordable, nutritious food.

“More than 800 million people live every day with hunger or food insecurity as their constant companion” World Hunger Statistics

Definition

Perinatal depression refers to major and minor episodes during pregnancy (termed antenatal) and/or within the first 12 months after delivery (termed postpartum or postnatal)

In South Africa there are many risk factors which may contribute to maternal mental illness, especially among women living in poverty.

Follow this link for a list of possible risk factors for common perinatal mental disorders.

Caring for Mothers

One out of every three women in South Africa suffers from depression during and after pregnancy.

Award-winning Director Simon Wood, spent time with Xolelwa in Khayelitsha, Cape Town, where rates of postnatal depression are three times higher than in developed countries.More stories of South African mothers

About our work

The Perinatal Mental Health Project (PMHP) promotes comprehensive maternal mental health services for South African women and informs local and global interventions through robust research and advocacy.

We also build the capacity of those who work with mothers to improve the quality of their care and provide mental health services for pregnant and postnatal women in Hanover Park, Cape Town.

Over the past two decades we have screened close to 40 000 pregnant women and counselled around 7 000 who needed support.